Gert van der Hoek
In Memoriam - Editor, Senior Moderator
Summary of Q-fever report in Noord- Brabant Province, Netherlands.
Full report
Author: Mirte Post
Executive summary
Q-fever is a zoonosis, which is a disease that spreads from animals to humans. In 2007 to 2010 the greatest outbreak in the world took place in the Netherlands with a peak of 2.355 patients in 2009. The highest rate of patients was in North-Brabant. These days the epidemic is dammed by measures in the veterinary sector. Now the outbreak is over the Provincial Council gave the assignment to exert an exploratory evaluation of the approach of the challenge of the Q-fever epidemic in North-Brabant from a human perspective.
With the help of interviews, the literature and a reconstruction of the actual happenings in the past years several aspects were judged. Here I present these aspects en its most important conclusions and recommendations. Then I summit the bottlenecks and their solutions and at last I put Q-fever in a broader perspective.
Measures in the veterinary sector
Actors were bided and thought: ‘It will pass’. Next there were a lot of aspects involved in Q-fever, which made it a complex story. These aspects include: the interests of het public health sector and the veterinary sector, the economic interests, the concise literature, the absence of a protocol, the absence of structures to take on the problem at a local level, the many actors that are involved and the Mexican flu in 2009.
I noticed that the environmental factors contribute for a large part in the public health. For this reason I believe it is important to integrate health in the environment policy.
Measures in the human sector
Diagnosis and treatment
The awareness among general practitioners is better nowadays and also the diagnosis, because a new test method was introduced. The treatment of acute Q-fever was clear, in contrary to the treatment of chronic patients and patients with persistent complaints. Two protocols were published for improvement of the treatment of chronic patients, but they do not mention patients with persistent complaints. This last group of patients often feels not understood by doctors and makes the best of it by their own ways.
A good process is the development of a general protocol for the treatment of Q-fever by the RIVM. I think that the awareness among general practitioners can be more improved to add an extra square to the apply form for a blood test. I believe that patients will be more comfortable if general practitioners and medical specialists take the time to calm down the patient by sharing their knowledge and showing understanding for the patients situation.
Clinics
The clinics are designed for chronic patients. Chronic Q-fever is a very rare form of Q-fever (has been reported with 1 to 3% of all patients) that can last for years. Chronic Q-fever starts dormant with complaints of tightness of the chest, fever, sweating, fatigue, and lose weight. Most people with chronic Q-fever have an inflammation of the heart valves (endocarditis). Chronic Q-fever is most common in patients with immune disorders and heart patients. Also pregnant women have an increased risk of chronic Q fever. (source: RIVM)
The group chronic patients with heart disease or immune disorders is already under the control of a medical specialist. The medical specialist must pay attention to additional symptoms and the occurrence of secondary disorders. Pregnant women are also already under control.
The group of patients with only an increased concentration of antibodies in their blood after a Q-fever infection can be as long as necessary under control of the family doctor.
The clinics are not meant for the group of patients with persistent fatigue complaints. This group of patients visit the clinic with wrong expectations.
I am of the opinion that the need for separate clinics for Q-fever should be reconsidered on the basis of information provided above, The various medical specialists and general practitioners must adequate work together to get the best therapy for the different groups of patients.
Human vaccine
The humane vaccine Q-vax existed already in 2007, but research on effectiveness and safety was exerted in 2010. Next the implementation takes time. By my means this process can be exerted faster.
Information
General information was long not available and was for the greatest part available on websites and in local papers. After 2009 patients, professions and citizens were informed quite well, but the leisure sector was not informed as well not the high risk patients.
The patients association is creating a new information brochure and I would recommend medical specialists to provide information to high risk patients. The general health care organization already created information for the leisure sector, they just need to send it.
Patients Association Q-uestion
The contact between patients is very good and the organization is working hard on the optimization of the information. I advise Q-uestion to improve the internal cooperation and work together with other Dutch patients associations to induce more power and show a stronger image.
Claims
I noticed claims are a hot item between patients. I recognize that it is the responsibility of the government to take a stand and communicate this clear to the patients. Which stand doesn’t matter if they adequately share this.
Research
Q-fever provides a lot of clues to start research at micro and macro level. A lot of this research at both the humane and the veterinary sector is exerted by the RIVM.
An attentive respondent made a clear point of that researchers also should as why some people don’t get sick. I believe we can profit by exploring possibilities for prevention and treatment more, because the bacterium is hard to eliminate.
Policy
Ratio health: veterinary
The ratio between the human and the veterinary aspect was not always equally in the spotlight, health was in the beginning the underdog. These days though health takes a more important place in het veterinary sector.
I realize the first bridge is built between the human and the veterinary sector and I believe the Province can strengthen this bridge by integrating health more in their environmental policy.
Cooperation
In general the cooperation between involved actors was good. The involved actors are the Province council for public health and social care, the general health organization, the mayors, the alderman’s, the Province, the general practitioners, the medical specialists and the patients. Improvement can be established in the cooperation between the human and veterinary sector and between the public health and individual care systems.
A great development in the improvement of the cooperation between the human and the veterinary sector is the establishment of the Brabants Knowledge Network Zoonoses. By my means this network should continue their good work. They can advise the public health and individual health care systems how to improve their cooperation. To continue their work the network does need enough resources.
Sharing knowledge
The next aspects are important if people share knowledge: you have to bring the actors quickly together, transparency in the process, placing the risk in a perspective and keep in mind that giving information is a bidirectional story. You also need to check if the information is received well.
I would recommend the Province to bring the actors that are involved quickly together and the general health care system to investigate whether the information is correctly received and place the risk in a perspective.
Division
I noticed it was unclear who to reach for action on Q-fever and it was also unclear who could be in charge and I also noticed that protocols or divisions were not available. I advise the Province to construct a protocol in cooperation with the involved actors in Q-fever. The following aspects can be part of this scenario.
• How can actors involved carry out one image to society and the media?
• How can they join forces to exert more influence and setting the agenda at the national government?
• How can they design an information flow between the human and veterinary sector? This is already established in North-Brabant by the Brabants Knowledge Network Zoonoses, set up in the early 2010.
• The municipal health service keeps playing a permanent role to play in the dissemination of information.
• In addition, the municipal health service monitors or more cases of disease occur within one or more regions.
• Last but not least, the province immediately brings together the actors involved for the construction of a plan of action. This plan shall take effect on the approach of the outbreak of the new zoonoses at regional level.
Finally
The following issues need to be - in my opinion- in direct center of attention. Therefore I evoke them once again.
• Almost all patients with long-term complaints, mainly fatigue, feel misunderstood by both their social and their working environment as their health care professionals. This does not promote the healing process. I recommend that the professionals going to help these patients to share their knowledge and understanding of the situation. The physicians can also refer them to Q-uestion in order to share experiences. Patients feel that they are not taken seriously by doctors, because doctors do not anticipate this situation. As a doctor takes time to talk to the patient, both the patients and the physician feels better. The municipal health service can start a campaign with information letters and information evenings to raise awareness among doctors in order to anticipate the situation of the patient.
• A second important point is the clinics. I understand that this clinics mean a lot of extra work for doctors and are not intended for the patient population with long-lasting complaints. The clinics are designed for chronic patients. The need for, and number of separate clinics for Q-fever should be reconsidered. The various medical specialists and general practitioners must adequate work together to provide the different groups of patients
atients with acute complaints, patients with chronic complaints and patients with long-lasting-complaints. It is necessary to stipulate an adequate and coordinated provision of information about the purpose of the clinic.
• A third point, which played a significant role in the fight of Q-fever was the absence of regional opportunities for the epidemic. The epidemic is concentrated in North-Brabant, which is why I recommend the County to construct a roadmap as described above for future zoonoses.
We can close the chapter Q-fever by immediately attention to the above bottlenecks and immediately act on. It is also important to put Q-fever in a broader perspective. Q-fever is a wake-up call for us and makes us think about organizational structures, the relationship between human and animal health, zoonoses in policy issues in the future etc. We want to be prepared. In order to achieve this it might be a first step to make people aware.
Be aware of what zoonoses are, how they affect different facets of life in North-Brabant and where we have a more frequent occurrence of zoonoses. These aspects can be treated in education from primary school to University and to all levels between the two. The Brabant Knowledge Network Zoonoses has considered and has started the implementation of the development of expertise in the professionals at the University.
This can be developed and be entered in the field of education in North-Brabant. A second step can be set by integrating health and the environment. Health risks can be a division of measures carried out in the environment. This can be entered in environment planning, building plans, and also to the future of intensive farm animals. What are the risks for public health by intensive farm animals? The first discussions on this subject are ongoing.
Full report
Author: Mirte Post
Executive summary
Q-fever is a zoonosis, which is a disease that spreads from animals to humans. In 2007 to 2010 the greatest outbreak in the world took place in the Netherlands with a peak of 2.355 patients in 2009. The highest rate of patients was in North-Brabant. These days the epidemic is dammed by measures in the veterinary sector. Now the outbreak is over the Provincial Council gave the assignment to exert an exploratory evaluation of the approach of the challenge of the Q-fever epidemic in North-Brabant from a human perspective.
With the help of interviews, the literature and a reconstruction of the actual happenings in the past years several aspects were judged. Here I present these aspects en its most important conclusions and recommendations. Then I summit the bottlenecks and their solutions and at last I put Q-fever in a broader perspective.
Measures in the veterinary sector
Actors were bided and thought: ‘It will pass’. Next there were a lot of aspects involved in Q-fever, which made it a complex story. These aspects include: the interests of het public health sector and the veterinary sector, the economic interests, the concise literature, the absence of a protocol, the absence of structures to take on the problem at a local level, the many actors that are involved and the Mexican flu in 2009.
I noticed that the environmental factors contribute for a large part in the public health. For this reason I believe it is important to integrate health in the environment policy.
Measures in the human sector
Diagnosis and treatment
The awareness among general practitioners is better nowadays and also the diagnosis, because a new test method was introduced. The treatment of acute Q-fever was clear, in contrary to the treatment of chronic patients and patients with persistent complaints. Two protocols were published for improvement of the treatment of chronic patients, but they do not mention patients with persistent complaints. This last group of patients often feels not understood by doctors and makes the best of it by their own ways.
A good process is the development of a general protocol for the treatment of Q-fever by the RIVM. I think that the awareness among general practitioners can be more improved to add an extra square to the apply form for a blood test. I believe that patients will be more comfortable if general practitioners and medical specialists take the time to calm down the patient by sharing their knowledge and showing understanding for the patients situation.
Clinics
The clinics are designed for chronic patients. Chronic Q-fever is a very rare form of Q-fever (has been reported with 1 to 3% of all patients) that can last for years. Chronic Q-fever starts dormant with complaints of tightness of the chest, fever, sweating, fatigue, and lose weight. Most people with chronic Q-fever have an inflammation of the heart valves (endocarditis). Chronic Q-fever is most common in patients with immune disorders and heart patients. Also pregnant women have an increased risk of chronic Q fever. (source: RIVM)
The group chronic patients with heart disease or immune disorders is already under the control of a medical specialist. The medical specialist must pay attention to additional symptoms and the occurrence of secondary disorders. Pregnant women are also already under control.
The group of patients with only an increased concentration of antibodies in their blood after a Q-fever infection can be as long as necessary under control of the family doctor.
The clinics are not meant for the group of patients with persistent fatigue complaints. This group of patients visit the clinic with wrong expectations.
I am of the opinion that the need for separate clinics for Q-fever should be reconsidered on the basis of information provided above, The various medical specialists and general practitioners must adequate work together to get the best therapy for the different groups of patients.
Human vaccine
The humane vaccine Q-vax existed already in 2007, but research on effectiveness and safety was exerted in 2010. Next the implementation takes time. By my means this process can be exerted faster.
Information
General information was long not available and was for the greatest part available on websites and in local papers. After 2009 patients, professions and citizens were informed quite well, but the leisure sector was not informed as well not the high risk patients.
The patients association is creating a new information brochure and I would recommend medical specialists to provide information to high risk patients. The general health care organization already created information for the leisure sector, they just need to send it.
Patients Association Q-uestion
The contact between patients is very good and the organization is working hard on the optimization of the information. I advise Q-uestion to improve the internal cooperation and work together with other Dutch patients associations to induce more power and show a stronger image.
Claims
I noticed claims are a hot item between patients. I recognize that it is the responsibility of the government to take a stand and communicate this clear to the patients. Which stand doesn’t matter if they adequately share this.
Research
Q-fever provides a lot of clues to start research at micro and macro level. A lot of this research at both the humane and the veterinary sector is exerted by the RIVM.
An attentive respondent made a clear point of that researchers also should as why some people don’t get sick. I believe we can profit by exploring possibilities for prevention and treatment more, because the bacterium is hard to eliminate.
Policy
Ratio health: veterinary
The ratio between the human and the veterinary aspect was not always equally in the spotlight, health was in the beginning the underdog. These days though health takes a more important place in het veterinary sector.
I realize the first bridge is built between the human and the veterinary sector and I believe the Province can strengthen this bridge by integrating health more in their environmental policy.
Cooperation
In general the cooperation between involved actors was good. The involved actors are the Province council for public health and social care, the general health organization, the mayors, the alderman’s, the Province, the general practitioners, the medical specialists and the patients. Improvement can be established in the cooperation between the human and veterinary sector and between the public health and individual care systems.
A great development in the improvement of the cooperation between the human and the veterinary sector is the establishment of the Brabants Knowledge Network Zoonoses. By my means this network should continue their good work. They can advise the public health and individual health care systems how to improve their cooperation. To continue their work the network does need enough resources.
Sharing knowledge
The next aspects are important if people share knowledge: you have to bring the actors quickly together, transparency in the process, placing the risk in a perspective and keep in mind that giving information is a bidirectional story. You also need to check if the information is received well.
I would recommend the Province to bring the actors that are involved quickly together and the general health care system to investigate whether the information is correctly received and place the risk in a perspective.
Division
I noticed it was unclear who to reach for action on Q-fever and it was also unclear who could be in charge and I also noticed that protocols or divisions were not available. I advise the Province to construct a protocol in cooperation with the involved actors in Q-fever. The following aspects can be part of this scenario.
• How can actors involved carry out one image to society and the media?
• How can they join forces to exert more influence and setting the agenda at the national government?
• How can they design an information flow between the human and veterinary sector? This is already established in North-Brabant by the Brabants Knowledge Network Zoonoses, set up in the early 2010.
• The municipal health service keeps playing a permanent role to play in the dissemination of information.
• In addition, the municipal health service monitors or more cases of disease occur within one or more regions.
• Last but not least, the province immediately brings together the actors involved for the construction of a plan of action. This plan shall take effect on the approach of the outbreak of the new zoonoses at regional level.
Finally
The following issues need to be - in my opinion- in direct center of attention. Therefore I evoke them once again.
• Almost all patients with long-term complaints, mainly fatigue, feel misunderstood by both their social and their working environment as their health care professionals. This does not promote the healing process. I recommend that the professionals going to help these patients to share their knowledge and understanding of the situation. The physicians can also refer them to Q-uestion in order to share experiences. Patients feel that they are not taken seriously by doctors, because doctors do not anticipate this situation. As a doctor takes time to talk to the patient, both the patients and the physician feels better. The municipal health service can start a campaign with information letters and information evenings to raise awareness among doctors in order to anticipate the situation of the patient.
• A second important point is the clinics. I understand that this clinics mean a lot of extra work for doctors and are not intended for the patient population with long-lasting complaints. The clinics are designed for chronic patients. The need for, and number of separate clinics for Q-fever should be reconsidered. The various medical specialists and general practitioners must adequate work together to provide the different groups of patients
atients with acute complaints, patients with chronic complaints and patients with long-lasting-complaints. It is necessary to stipulate an adequate and coordinated provision of information about the purpose of the clinic.• A third point, which played a significant role in the fight of Q-fever was the absence of regional opportunities for the epidemic. The epidemic is concentrated in North-Brabant, which is why I recommend the County to construct a roadmap as described above for future zoonoses.
We can close the chapter Q-fever by immediately attention to the above bottlenecks and immediately act on. It is also important to put Q-fever in a broader perspective. Q-fever is a wake-up call for us and makes us think about organizational structures, the relationship between human and animal health, zoonoses in policy issues in the future etc. We want to be prepared. In order to achieve this it might be a first step to make people aware.
Be aware of what zoonoses are, how they affect different facets of life in North-Brabant and where we have a more frequent occurrence of zoonoses. These aspects can be treated in education from primary school to University and to all levels between the two. The Brabant Knowledge Network Zoonoses has considered and has started the implementation of the development of expertise in the professionals at the University.
This can be developed and be entered in the field of education in North-Brabant. A second step can be set by integrating health and the environment. Health risks can be a division of measures carried out in the environment. This can be entered in environment planning, building plans, and also to the future of intensive farm animals. What are the risks for public health by intensive farm animals? The first discussions on this subject are ongoing.